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Is a nursing home covered by Medicare for seniors?

4 min read

According to the Centers for Medicare & Medicaid Services, Original Medicare does not pay for long-term custodial care, which is what most nursing home residents require. So, is a nursing home covered by Medicare for seniors? The answer is generally no, but with a few crucial exceptions for short-term, medically necessary care.

Quick Summary

Original Medicare does not cover long-term nursing home care, which is primarily custodial. Coverage is limited to short-term stays in a skilled nursing facility following a qualifying hospital stay, with cost-sharing after 20 days. Other options like Medicaid and private insurance exist.

Key Points

  • Limited Skilled Care Coverage: Medicare only covers short-term, medically necessary stays (up to 100 days) in a skilled nursing facility (SNF) after a qualifying hospital stay.

  • No Long-Term Custodial Care: Medicare does not pay for long-term custodial care, which includes help with daily activities like bathing and dressing.

  • Specific Eligibility Requirements: To qualify for SNF coverage, you must have an inpatient hospital stay of at least three days, need daily skilled care, and enter a Medicare-certified SNF within 30 days of hospital discharge.

  • Cost-Sharing Applies: For a covered SNF stay, Medicare pays 100% for the first 20 days, but patients are responsible for a daily coinsurance from day 21 through day 100.

  • Explore Other Funding Options: For long-term care needs, consider other payment sources like Medicaid, long-term care insurance, personal assets, or veterans benefits.

  • Medicare Advantage Plans Vary: Medicare Advantage (Part C) plans also cover skilled nursing care, but cost-sharing and network rules can differ. Always check with your specific plan.

  • Observation Status Impacts Coverage: Time spent in the hospital under 'observation status' does not count toward the three-day inpatient stay required for SNF coverage.

In This Article

Understanding Medicare's Limited Nursing Home Coverage

Navigating the world of senior healthcare can be confusing, especially when it comes to nursing home care. Many people mistakenly believe that Medicare will cover the significant costs of an extended nursing home stay. However, Medicare coverage for this type of care is very limited and specific. It is essential for seniors and their families to understand the distinctions between different types of care and the specific criteria that must be met for any coverage to apply.

Custodial Care vs. Skilled Nursing Care

The core of Medicare's coverage limitations lies in the difference between custodial and skilled care. Most of what is provided in a long-term nursing home stay is considered custodial care, which Medicare generally does not cover.

  • Custodial Care: This non-medical care helps with activities of daily living (ADLs), including bathing, dressing, eating, and using the bathroom. It is the primary form of care for long-term nursing home residents.
  • Skilled Nursing Care: This is medical care that requires the skills of licensed professionals. Medicare Part A may cover short-term stays in a skilled nursing facility (SNF) for this type of care after a qualifying hospital stay.

The Specific Requirements for Skilled Nursing Facility (SNF) Coverage

To receive Medicare coverage for a stay in a skilled nursing facility, you must meet a strict set of conditions. This includes a qualifying hospital stay of at least three consecutive days, a doctor's order for daily skilled care, and admission to a Medicare-certified SNF within 30 days of leaving the hospital.

How Long Does Medicare Cover a Skilled Nursing Stay?

Medicare's coverage for a skilled nursing stay is limited per benefit period. For days 1-20, Medicare covers the entire cost. From days 21-100, a daily coinsurance applies (For 2025, this is $209.50). After day 100, you are responsible for all costs.

Comparison of Paying for Nursing Home Care

For long-term care needs, families must look beyond Medicare. The following table compares common payment methods.

Payment Method What It Covers Cost and Eligibility Considerations
Original Medicare (Part A) Short-term skilled nursing facility (SNF) care for up to 100 days, after a qualifying hospital stay. Daily coinsurance required for days 21-100. No coverage after 100 days. Only for medically necessary, rehabilitative care, not long-term custodial care.
Medicaid Long-term custodial and medical care in a nursing home for eligible individuals. Based on state-specific low-income and limited asset requirements. Pays 100% of care for eligible residents. Strict eligibility rules and asset limits. Some states have "spend down" requirements.
Long-Term Care Insurance Can cover a variety of long-term care services, including custodial care in a nursing home or assisted living facility. Premiums are based on age and health. Benefits begin after a predetermined waiting period and usually have a daily benefit limit. Must be purchased well in advance. Relatively few people have it.
Private Pay/Personal Assets Any care not covered by insurance, using personal savings, pensions, retirement accounts, or other assets. Costs for nursing home care are very high, with a median monthly cost over $9,000 for a semi-private room. Can quickly deplete savings. Many residents pay privately until they exhaust funds and become eligible for Medicaid.
Veterans Benefits Some benefits, such as the Aid and Attendance program, can help eligible veterans and their surviving spouses pay for long-term care. Eligibility depends on service record, income, and assets. Specific criteria must be met. Can provide significant financial relief for qualified individuals.

Alternatives to Long-Term Nursing Home Care

For seniors who require ongoing care but do not need a skilled nursing facility, other options may be more suitable:

  • Home Health Care: Medicare may cover some intermittent skilled nursing care and therapy services at home if specific criteria are met.
  • Assisted Living: Medicare does not cover room and board, but medically necessary services for residents with Original Medicare are covered by Part B.
  • Hospice Care: For terminal illness, Medicare Part A covers hospice care, including services in a nursing home, but not room and board.
  • Medicaid Waivers: State-specific programs may help cover long-term care services at home or in the community.

Conclusion

Medicare does not provide extensive coverage for long-term nursing home stays, which primarily involve custodial care. Coverage is limited to short-term, medically necessary stays in a skilled nursing facility, up to 100 days per benefit period with coinsurance after 20 days. Long-term care requires alternative funding sources like personal assets, long-term care insurance, or Medicaid. Understanding these differences is crucial for planning.

For more detailed information on covered services and eligibility requirements, it is best to consult the official Medicare website.

Frequently Asked Questions

A nursing home typically provides long-term custodial care, which Medicare does not cover. A skilled nursing facility (SNF) provides short-term, medically necessary care, which may be covered by Medicare for up to 100 days.

No, time spent under 'observation status' in a hospital does not count toward the three-day inpatient hospital stay requirement for Medicare to cover a skilled nursing facility stay.

Medicare Advantage plans must cover at least the same benefits as Original Medicare, including skilled nursing facility stays. However, cost-sharing and facility networks may differ, so check your specific plan's details.

Medicare Part A will pay for up to 100 days of skilled nursing facility care per benefit period. You pay nothing for the first 20 days, but a daily coinsurance is required for days 21 through 100.

Medicare does not cover long-term custodial care, even for chronic conditions like dementia. It will only cover medically necessary services, not the cost of the nursing home itself.

After day 100 of a skilled nursing stay, Medicare coverage for that benefit period ends, and you are responsible for all costs. You would then need to explore alternative payment methods.

Most Medigap policies help cover the daily coinsurance cost for a skilled nursing facility stay from day 21 through day 100. However, like Medicare, they do not cover long-term custodial care.

References

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Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.